The Combined Oral Contraceptive Pill Versus Bromocriptine to Puerperal Fever

Document Sample
The Combined Oral Contraceptive Pill Versus Bromocriptine to  Puerperal Fever Powered By Docstoc
					      The Combined Oral Contraceptive Pill Versus
  Bromocriptine to Suppress Lactation in Puerperium : A
            Randomized Double Blind Study
                                         Manee Piya-Anant MD*,
                            Suporn Worapitaksanond MA*, Kitinan Sittichai BA*,
                              Porndara Saechua BA*, Anantaporn Nomrak BA*

 * Department of Obstetrics and Gynaecology, Faculty of Medicine, Siriraj Hospital, Mahidol University


         A randomised double blind comparative study of 230 HIV infected mothers who had a normal
delivery at 37-42 weeks’ gestation were divided into two groups; 116 combined pill users and 114
bromocriptine users to suppress lactation. There were 33 cases (28.5%) of combined pills users and 29 cases
(25.4%) of bromocriptine users who had breast engorgement without statistical difference. All of them had
mild breast engorgement without any treatment except one case (0.9%) in the bromocriptine group had
severe breast engorgement with puerperal fever and needed an analgesic drug. There were no side effects of
the drugs. This study showed that combined pills were beneficial to suppress lactation in HIV infected
mothers to prevent postnatal mother-to-child transmission because of low risk and low cost.

Keywords : Suppress lactation, Combined pills, Bromocriptine, HIV infected mother, Breast engorgement

J Med Assoc Thai 2004; 87(6): 670-3


Rationale                                                    Thailand, our national policy is to avoid breast-
          Transmission of Human Immunodeficiency             feeding to prevent postnatal transmission from HIV
Virus (HIV) from mother to child is a large problem in       infected mother so that suppression of lactation in
obstetrics. Vertrical transmission during pregnancy          the puerperal is needed.
and labour has been reported at 24% - 38.5%(1-4). There                Prolactin level is high during the early
are many reports of postnatal transmission during            postpartum period. Prolactin will stimulate milk
breast feeding(5-7). Breast milk transmission of HIV-1       production within 3-4 days of delivery so that breast
can occur at any time during the entire duration of          engorgement will last about 48-72 hours(11). Mothers
breastfeeding. The risk of late postnatal transmission       with breast engorgement usually experience pain and
(after 2.5 months of age) is 3.2 per 100 child/years of      fever so suppression of lactation can prevent these
breastfeeding(8). Mastitis, an inflammation of the           symptoms.
breast, has recently been linked to a higher human                     There are many methods to suppress
immunodeficiency virus load in breast milk (9).              lactation. Breast binding can decrease stimulation of
Avoidance of breastfeeding can prevent postnatal             the nipple and the milk ejection reflex but 60% of
transmission to a child who may not be infected.             lactating mother still had breast engorgement from
However, countries where the risk of death in the first      day 3-5 postpartum(12). High dose estrogen reduces
year of life is 50% from diarrhea and other diseases         lactation in 86% (13) but increses the risk of postpartum
(excluding AIDS) breastfeeding is still the feeding          thromboembolism by three times that of postpartum
method of choice. Clemen(10) reported that infants in        thromboembolism(14). Bromocriptine has been used
whom breastfeeding was initiated early had a 20%             worldwide since 1980 for the prevention of breast
lower rate of diarrhea than in those initiated late. In      engorgement in the puerperium(15). A comparative
                                                             study between high dose estrogen and bromcriptine
Correspondence to : Piya-Anant M, Department of Obstetrics   showed that bormocriptine had a better outcome(12).
and Gynaecology, Faculty of Medicine, Siriraj Hospital,
Mahidol University, Bangkok 10700, Thailand.
                                                             Many reports(15-17) showed that using bromocriptine


J Med Assoc Thai Vol. 87 No.6 2004
during the puerperium increases the risk of                clinical and demographic characteristics of both
vasospasm especially in those with pregnancy               groups were similar (Table 1). The average age was
induced hypertension. At present, the use of prophy-       23.2 + 4.6 years in combined pill users and 24.3 + 5.1
lactic antiretroviral treatments has brought about a       in bromocriptine users. Body mass indices were 25.1
dramatic decrease in the risk of transmission(18) but      + 4.7 and 24.9 + 4.0 kg/m2 respectively. The obstetric
have shower progress in ablactation.                       histories of both groups were also similar; The
                                                           majority were primigravida and, the gestational age
Objective                                                  of the pregnancy was 39.4 + 1.6 and 38.8 + 1.5 weeks
          To compare the effect outcome of bromocrip-      in the combined pill group and the bromocriptine
tine and a combined oral contraceptive pill containing     group respectively. There were 33 cases (28.5%) of
50 micrograms ethinyl estradiol in the supression of       breast engorgement in the combined pill users and 29
lactation in the puerperium.                               cases (25.4%) in the bromocriptine users (Table 2). In
                                                           the combined pill group, there were 0.9%, 3.4%, 10.3%,
Material and Method                                        9.5% and 4.3% who had breast engorgement on the
          A randomised double blind comparative            first day, second day, third day, fourth day and fifth
study of 230 asymptomatic HIV infected mothers             day after delivery respectively. In the bromocriptine
aged between 18-35 years. All subjects had a normal        group, there were 1.8%, 4.4%, 7.9%, 7.9% and 3.5%
delivery at 37-42 weeks’ gestation and were willing        who had breast engorgement on the first day, second
to participate in this study and signed the consent        day, third day, fourth day and fifth day respectively.
form. The subjects were randomised by computer to          All of them had mild breast engorgement except one
either bromocriptine or a combined pill containing         in the bromocriptine group who had severe breast
50 micrograms of ethinyl estradiol two tablets twice       engorgement and needed analgesics (Table 3). There
a day for 5 days. Both drugs were put into the same        were no side effects of the drugs seen in this study.
type of capsule so that both patient and doctor were
“blind” to the treadment. The first dose of drug was
given within 12 hours of delivery. Signs and symptoms
of breast engorgement and any side-effects of the          Table 1. Characteristics of women in the study according to
                                                                    type of medication. Received figures are percentage
drugs were recorded daily by a different group of
doctors and nurses until 12 hours after the last dose.     Characteristic             Combined pills            Bromocriptine
The degree of breast engorgement was identified as                                       N = 116                   N = 114
mild or severe. Mild breast engorgement was defined
as generalized tenderness and/or generalized swelling      Age (year)                   23.2    +   4.7          24.3   +   5.1
                                                           BMI (Kg/m 2 )                25.1    +   4.7          24.9   +   4.0
with heat of the breast. Severe breast engorgement was
                                                           Gestational age (week)       39.4    +   1.6          38.8   +   1.5
defined as generalized tenderness and/or generalized       Abortion                      0.7    +   0.4           0.7   +   0.5
swelling with heat plus puerperal fever.                   Gravida                       1.7    +   0.9           1.8   +   0.9
          The exclusion criteria were
          1. Subjects at high risk for taking a combined
pill with a high dose of estrogen were those more than
35 years old, overweight or with a past history of a
thromboembolic episode.                                    Table 2. Day that breast engorgement commenced according
          2. Subjects at high risk for taking bromocrip-            to the drug used to suppress lactation
tine were those with pregnancy-induced hypertension,                           Combined pill              Bromocriptine
seizure, stroke or myocardial infarction.                                        (n = 116)                  (n = 114)

Results                                                                        No.        %               No.           %
        From January 1997 to December 1998 there
                                                           First day             1        0.9              2             1.8
were 230 HIV infected mothers who delivered and            Second day            4        3.4              5             4.4
were willing to paticipate in this study. The subjects     Third day            12       10.3              9             7.9
were divided into two groups; 116 subjects took the        Fourth day           11        9.5              9             7.9
combined oral contraceptive pill and 114 subjects          Fifth day             5        4.3              4             3.5
took bromocriptine in order to suppress lactation. The     Total                33       28.5             29            25.4



J Med Assoc Thai Vol. 87 No.6 2004                                                                                             671
Table 3. Severity of breast engorgement according to drug             The authors concluded that combined oral
         used to suppress lactation                         contraceptive pill is beneficial to suppress lactation
Breast endorgement      Combined pills   Bromocriptine
                                                            in postpartum women such as HIV infected mothers,
                                                            because action of a combined pill similar to bromocrip-
                         No.     %        No.     %         tine but the cost of a combined pill was lower and the
                                                            side effects of a combined pill in Thai women were
Severe                    0       0        1      0.9       very low.
Mild                     33      28.5     28     24.6
None                     83      71.6     85     74.6
Total                   116     100.1    114    100.1       References
                                                             1. Halsey NA, Boulos R, Holt E, Ruff A, Brutus JR,
                                                                Kissinger P, et al. Transmission of HIV-1 infections
                                                                from mothers to infants in Haiti. JAMA 1990; 264:
Discussion                                                      2088-92.
          Precautions for antepartum, peripartum, and        2. The Europian Collaborative Study. Mother-to
postpartum care of infected mothers and infants are             child transmission of HIV infection. Lancet 1998; 2:
                                                                1039-42.
important. In management during pregnancy, a number
                                                             3. Hira SK, Mangrola UG, Mwale C, Chintu C, Tembo
of investigations have shown that a combination of              G, Brady WE, et al. Apparent vertical transmission of
nucleoside analogs given along with a protease                  human immunodeficiency virus type 1 by breastfeeding
inhibitor is highly effective in suppression of HIV-            in Zambia. J Pediatr 1990 ; 117 : 421-4.
RNA levels(19). Wade et al colleague(20) reported that       4. Editorial. Breastfeeding during the HIV epidemic, the
perinatal transmission rate was 8% if zidovudine                dilemma: preventing vertical transmission or preventing
was begun in the prenatal period, 10% if given only             death. J Trop Pediatr 1994; 40: 64-5.
intrapartum, and 9% if given to the newborn within           5. Stiehm ER, Vink P. Transmission of human
the first 48 hours. Stiehm et al(21) reported that              immunodeficiency virus infection by breast-feeding. J
zidovudine prophylaxis is also highly effective in              Pediatr 1991; 118: 410-2.
                                                             6. Perre Van de Perre P, Simonon A, Msellati P, Hitimana
reducing perinatal transmission in women with
                                                                DG, Vaira D, Bazubagira A. et al. Postnatal trans-
advanced disease.                                               mission of human immunodeficiency virus type 1 form
          Breast milk increases the risk of neonatal            mother to infant. N Engl J Med 1991; 325: 593-8.
transmission. It has been estimated that one to two          7. Ziegler JB, Johnson RO, Cooper DA, Gold J. Postnatal
thirds of maternal transmission in breast-fed-intants           transmission of AID-associated retrovirus from mother
is from breast milk(22). In general, breastfeeding is not       to infant. Lancet 1985; 1: 896-9.
recommended in HIV-positive women. Suppressing               8. Vande Perre P. Breast milk transmission of HIV-1.
lactation is needed to prevent breast engorgement.              Laboratory and Clinical study. Ann NY Acad Sci 2000;
The figures for mild and severe breast engorgement              918: 122-7.
in both combined pill users and those taking                 9. Semba RD. Mastitis and transmission of human
                                                                immunodeficiency virus through breast milk. Ann NY
bromocriptine were very low in the present study
                                                                Acad Sci 2000; 918: 156-62.
compared with the study of Almeida and Kitay(23).           10. Clemen J, Elyazeed RA, Rao M, et al. Early initiation
They found an incidence of puerperal fever from                 of breastfeeding and the risk of infant diarrhea in rural
breast engorgement of 13.3% in mothers using                    Egypt. Pediatrics 1999; 104: e3.
bromocriptine to suppress lactation.                        11. Lawrence RA, ed. Breastfeeding. 4th ed. ST. Louis:
          These was no statistical difference in the            Mosby-Year Book, 1994: 203-77.
severity of breast engorgement between the                  12. Shearman RP, ed. Clinical reproductive endocrinology.
combined pill and bromocripine users. This shows                Hong Kong : Longman Group Limited, 1985: 294-6.
that both combined pills and bromocriptine can              13. Walker S, Groom G, Hibbard BM, Griffiths K.
suppress lactation to a similar degree. There were no           Controlled trial of bromocriptine, quinoestrol, and
                                                                placebo in suppression of puerperal lactation. Lancet
side effects or risk from either drug used in the
                                                                1975; 2: 842-5.
present. Chumnijarakij(24) reported that postpartum         14. Millar DG, Littlepage BNC. Puerparal thromboem-
thromboembolism in Thai women is very rare when                 bolism. Lancet 1970; 1: 887.
compared with European women. This supports the             15. Iffy L, O’Donnell J, Corrcia J, Hopp L. Severe cardiac
benefit of a combined oral contraceptive pill to suppress       dysrhythmia in patient using bromocriptine
lactation as it has low cost and has a low risk.                postpartum. Am J Therapeutics 1998; 5: 111-5.


672                                                                              J Med Assoc Thai Vol. 87 No.6 2004
16. Hopp L, Haider B, Iffy L. Myocardial infarction           21. Stiehm ER et al. Efficacy of zidovodine and humna
    postpartum in patients taking bromocriptine for the           immunoheficiency virus (HIV) hyperimmune
    prevention of breast engorgement. Int J Cardiology            immunoglogulin for reducing perinatal HIV trans-
    1996; 57: 227-32.                                             mission from HIV-infected women with advanced
17. Iffy L. Lethal cardiovascular complications in patients       disease: Results of Pediatric AIDS Clinical trial group
    receiving bromocriptine for ablactation. Med Law              protocol 185. J Infect Dis 1999; 179: 567-75.
    1994; 14: 99-104.
                                                              22. Van de Perre P. Transmission of human immuno-
18. Kijak GH, Avila MM, Salomon H. Mother-to-child
                                                                  deficiency virus type 1 through breastfeeding: how
    transmission of drug-resistant HIV. Drug Resist Update
                                                                  can it be prevented ? J Infect Dis 1999; 179: S405-7.
    2001; 4: 29-37.
19. Carpenter CC et al. Antiretroviral therapy for HIV        23. Almeida OD, Kitay DZ. Lactation suppression
    infection in 1996. JAMA 1996; 276: 146-54.                    and puerperal fever. Am J Obstet Gynecol 1986; 154:
20. Wade Na et al. Abbreviated regimens of zidovudine             940-1.
    Prophylaxis and perinatal transmission of the human       24. Chumnijarakij T. Incidence of postpartum thromboem-
    immunodeficiency virus. N Engl J Med 1998; 339:               bolism in Thai woman: comparison with Western
    1409-14.                                                      Experience. J Med Ass Thai 1974; 57: 592-4.




                        ้      ่
ศึกษาเปรียบเทียบการยับยังการหลังน้ำนมของยาเม็ดคุมกำเนิดและ Bromocriptine

(ขาดชื่อผู้แต่งภาษาไทย)

         การศึกษาเปรียบเทียบโดยวิธี randomised double blind ผลของยาเม็ดคุมกำเนิด (combined pill) และ
bromocriptine ในการยับยั้งการหลั่งน้ำนมในมารดาที่ติดเชื้อเอดส์ ที่คลอดปกติทางช่องคลอดเมื่ออายุครรภ์
37-42 สัปดาห์ จำนวน 230 ราย โดยแบ่งผู้ป่วยเป็น 2 กลุ่มโดย 116 รายใช้ยาเม็ดคุมกำเนิด และ 114 รายใช้
bromocriptine ในการยับยั้งการหลั่งน้ำนม จากผลการศึกษาพบว่า ร้อยละ 28.5 ในกลุ่มที่ใช้ยาเม็ดคุมกำเนิด
และร้อยละ 25.4 ในกลุ่มที่ใช้ bromocriptine ยังมีอาการนมคัดผลที่ได้ไม่แตกต่างกันทางสถิติ อาการนมคัด
ส่วนใหญ่มีอาการไม่มาก ยกเว้นหนึ่งรายคิดเป็น ร้อยละ 0.9 ในกลุ่มที่ใช้ bromocriptine มีอาการนมคัดมาก
จนต้ อ งใช้ ย าแก้ ป วด และจากผลการศึ ก ษาไม่ พ บอาการแทรกซ้ อ นของยา แสดงให้ เ ห็ น ว่ า ยาเม็ ด คุ ม กำเนิ ด
สามารถยับยั้งการหลั่งน้ำนมได้ดีอย่างน้อยเท่า bromocriptine แต่มีข้อดีกว่าเพราะยาเม็ดคุมกำเนิดราคาถูก
และหาได้ง่ายกว่า


J Med Assoc Thai Vol. 87 No.6 2004                                                                                   673

				
DOCUMENT INFO
Shared By:
Categories:
Stats:
views:22
posted:8/8/2010
language:English
pages:4
Description: The Combined Oral Contraceptive Pill Versus Bromocriptine to Puerperal Fever